Job Application Form

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• Position Applied For • Where did you see this post advertised? 1. PERSONAL DETAILS • Surname • Title (Mr,Mrs,Miss,Ms,other) • Forenames Previous other surname • Current Address • Post Code • National Insurance No. • Telephone No. Mobile No. • Email address 2. EDUCATION • School • Qualification/s • Date Obtained College Qualification/s Date Obtained 3. PROFESSIONAL/TECHNICAL QUALIFICATIONS OR MEMBERSHIP Name and Address of Training School Entry Date Leaving Date Qualification gained N.M.C. P.I.N Expiry Date 4. PRESENT EMPLOYER Employer’s Name Address Position held/grade Present salary Reasons for wishing to leave Period of notice 5. EMPLOYMENT HISTORY FOR THE PAST TEN YEARS - MOST RECENT FIRST – ANY GAPS MUST BE ACCOUNTED FOR. Full CV acceptable Employer 1 Date From Date To Position Reason for Leaving Salary Employer 2 Date From Date To Position Reason for Leaving Salary Employer 3 Date From Date To Position Reason for Leaving Salary Additional roles 6. DISCIPLINARY ACTION. Have you been subject to any disciplinary action in the last 12 months, or are you subject to any current or impending disciplinary action If Yes, please provide details 7. REFERENCES Please give the full names and addresses of TWO PROFESSIONAL REFEREES (not relatives/friends) one of whom must be your PRESENT employer (or most recent if unemployed). School leavers should quote the Head-teacher. • Name • Position • Address • Postcode • Telephone number • Email address • Known in what capacity to you • Known for how long (years & months) • Name • Position • Address • Postcode • Telephone number • Email address • Known in what capacity to you • Known for how long (years & months) • 8. DETAILS OF EXPERIENCE AND SKILLS RELEVANT TO THE JOB Please summarise why you feel that you are suitable for this post with reference to any previous experience. 9. REHABILITATION OF OFFENDERS DECLARATION Have you been referred for inclusion on the POVA list? Have you been convicted of any criminal offence at any time? If so, please give details of the conviction(s) and the date(s) • Signed (with a X) • Date N.B. Any information disclosed will be taken into consideration but will not automatically prevent your application from proceeding. However, if you are appointed, failure to disclose any criminal conviction could lead to termination of your employment. 10. DECLARATION I declare that to the best of my knowledge and belief the information given is true, and I understand that the giving of false or misleading statements or withholding material information may result in disciplinary action including dismissal. • Signed (with a X) • Date EQUALITY AND DIVERSITY POLICY The Regency Nursing Home requires fair and equal treatment of all applicants who will be judged only on their ability to do the job for which they are applying. It is for this reason only that you are asked to provide the information below. It is hoped that the questions in this context will in no way give cause for offence. The information you give will be treated in the strictest confidence and used for statistical purposes only in the interests of equality and diversity and is separate from the main application form. If you have any queries about this form please contact Mr or Mrs Bungaroo. • Name Are you? How would you best describe your ethnic origin? White Mixed Asian & Asian British Black or Black British Chinese or Other Ethnic Group The Disability Discrimination Act (1995) defines a disabled person as: ‘a person who has or has had in the past a physical or mental impairment which has a substantial and long term adverse effect on their ability to carry out normal day-to-day activities’. Under this definition, do you consider yourself to be disabled? Upload your CV